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lnfoCard#:ABMT-GEN-025FRM1 Rev. 03 Effective Date: 09 Aug 2019
DukeMedicine Division of Cellular Therapy
DOCUMENT NUMBER: ABMT-GEN-025 FRM1
DOCUMENT TITLE:
Physician Photopheresis Note FRM1
DOCUMENT NOTES:
Document Information
Revision: 03 Vault: ABMT-General-rel
Status: Release Document Type: General
Date Information
Creation Date: 02 Aug 2019 Release Date: 09 Aug 2019
Effective Date: 09 Aug 2019 Expiration Date:
Control
Author:
Previous
Information
MC363
Number: ABMT-GEN-025 FRM1 Rev C_n
Owner:
Change
MC363
Number: ABMT-CCR-270
CONFIDENTIAL - Printed by: ACM93 on 09 Aug 2019 08:46:55 am
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FormM 0345
lnfoCard#:ABMT-GEN-025FRM1 Rev. 03 Effective Date:
DUKE UNIVERSITY HEALTH SYSTEM
p9 Aug 2019
Name:
History #:
ABMT-GEN-025 FRM 1 Physician Photopheresis Note
Procedure Date: / /
Procedure: Extracorporeal Photopheresis (ECP)CPT Code: 36522
Rationale:
a ECP has shown to have an immunomodulatory effect in treating the clinical manifestations of graft vs.host disease (GVHD).a ECP has shown to have an immunomodulatory effect in treating the clinical manifestations ofcutaneous T-cell lymphoma (CTCL).D ECP has shown to have an immunomodulatory effect in treating the clinical manifestations of solidorgan allograft rejection, bronchiolitis obliterans syndrome (BOS), and some autoimmune disorders.
Patient Status Prior to Treatment:
D The patient was seen. Vital signs, laboratory results, and ECV% within normal limits. Patient clearedto proceed with treatment.a The patient was seen. Out of range notification factors discussed. Patient cleared to proceed withtreatment. Plan discussed with apheresis nurse.
Potential Side Effects:
. Hypotension due to the extracorporeal blood volume. This can be treated with fluid replacement.
. Clotting: clots can occur in the lumen of the IV catheter. These clots can be lysed, or dissolved,with Alteplase. This can be done by the apheresis nurse in the ABMT clinic.
. Catheter infection: the risk of infection occurs with any catheter insertion and may necessitateremoval of the device.
. Anemia: Blood counts will be monitored each week. A manual blood return will be performedeach procedure to minimize any blood volume loss.
Procedure: ECP was performed at the Adult Bone Marrow Transplant Clinic using the THERAKOSCELLEX.
The procedure was performed via the patient's:D Central Venous Access Device D Peripherally inserted IV line.
Patient Status:
. The patient tolerated the procedure well: DYes DNo
. Side Effects: DAnemia DClot DHypotension DInfection D Other
Physician Signature
ABMT-GEN-025 FRM1 Physician Photopheresis NoteABMT, DUMCDurham, NC
Date
CONFIDENTIAL - Printed by: ACM93 on 09 Aug 2019 08:46:55 am
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InfoCard #: ABMT-GEN-025 FRM1 Rev. 03 Effective Date: 09 Aug 2019
Signature Manifest
Document Number: ABMT-GEN-025 FRM1
Title: Physician Photopheresis Note FRM1Revision: 03
All dates and times are in Eastern Time.
ABMT-GEN-025 FRM1 Physician Photopheresis Note
Author
Name/Signature Title
Mary Beth Christen (MC363)
Management
Date
08 Aug 2019, 09:56:03 AM Approved^Mea^ing/Reason^
[J^arne/S^gnature^Jennifer Frith (JLF29)
Medical Director
Title I Date ̂ ___I Meaning/Reason08 Aug 2019, 10:26:50 AM Approved
Name/SignatureNelson Chao (CHA00002)
Quality
Title I Date I Meaning/Reason08 Aug 2019, 12:55:22 PM Approved
Name/SignatureBing Shen (BS76)
Document Release
Title Date Meaning/Reason08 Aug 2019, 02:24:59 PM Approved
Name/Sig nature _LllS!?.Betsy Jordan (BJ42)
Date Meaning/Reason
08 Aug 2019, 03:02:58 PM Approved
CONFIDENTIAL - Printed by: ACM93 on 09 Aug 2019 08:46:55 am
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